Lower-extremity arteriovenous access for haemodialysis: a systematic review.

BACKGROUND: The lower extremity is increasingly used as an access site in end-stage renal disease patients. However, reports present conflicting results, creating confusion regarding the feasibility and outcomes. Our objective is to review the available literature and analyse the patency rates and complications of various types of lower-extremity arteriovenous access. METHODS: An Internet-based literature search was performed using MEDLINE to identify all published reports on lower-extremity vascular access. The analysis involved studies comprising at least 10 arteriovenous accesses with both inflow and outflow vessels in the lower extremity, and reporting on patency rates and access-related complications. The weighted mean patency rates were calculated, and the chi-square (chi(2)) test was used to evaluate the differences in the complication rates in the subgroups of patients identified. RESULTS: Three main types of lower-extremity vascular access were identified: the upper thigh prosthetic, the mid-thigh prosthetic and the femoral vein transposition arteriovenous access. There are limited data on saphenous vein loop grafts, which report poor results. The weighted mean primary patency rates at 12 months were 48%, 43% and 83%, respectively. The weighted mean secondary patency rates at 12 months were 69%, 67% and 93%, respectively. Access loss as a result of infection was more common in upper thigh and mid-thigh grafts than femoral vein transposition arteriovenous access (18.40%, 18.33% vs. 1.61%; P<0.05). Ischaemic complications rates were higher in autologous than prosthetic arteriovenous access (20.97% vs. 7.18%, P<0.05). CONCLUSIONS: Lower-extremity vascular access has acceptable results in terms of patency, with femoral vein transposition having better patency rates than femoral grafts. Autologous access is associated with less infective complications, however, at the expense of increased ischaemic complications rates. Further research with randomised trials is required to assess the outcomes of lower-extremity vascular access.

Diagnostic criteria and treatment of Buerger's disease: a review.

Buerger's disease is an inflammatory occlusive disorder affecting the small and medium-size arteries and veins of young, predominantly male, smokers. The disorder has been identified as an autoimmune response triggered when nicotine is present. Tobacco abuse is the major contributing risk factor; however, smoking seems to be a synergistic factor rather than the cause of the disease. The traditional diagnosis of Buerger's disease is based on 5 criteria (smoking history, onset before the age of 50 years, infrapopliteal arterial occlusive disease, either upper limb involvement or phlebitis migrans, and absence of atherosclerotic risk factors other than smoking). As there is no specific diagnostic test and an absence of positive serologic markers, confident clinical diagnosis should be made only when all these 5 criteria have been fulfilled although not universally accepted. The angiographic findings in Buerger's disease ("corkscrew," "spider legs," or "tree roots") are helpful but not pathognomonic. A wide spectrum of medical or surgical therapeutic options have been proposed; however, total abstinence from tobacco use remains the only means of stopping the disease progression. The initial management of patients with Buerger's disease should be conservative. Because several arteries may be unaffected, claudicants should be encouraged to walk, whereas patients with "critical" ischemia should be admitted for bed rest in the hospital. Bypass grafting is seldom an option, as the location of the lesions distally leaves little to bypass because of lack of target vessels. A literature review revealed only a few series reporting vascular reconstruction (mainly femorodistal bypasses) in Buerger's disease. Bypass patency rates were suboptimal; however, the corresponding limb salvage rates were satisfactory. A possible explanation is that patent grafts, even over a short period of time, are sufficient to allow healing of ulcers in patients with Buerger's disease.

Antiplatelet treatment and prothrombotic diathesis following endovascular abdominal aortic aneurysm repair.

Prothrombotic diathesis expressed by elevated levels of coagulation-specific biomarkers has been reported in patients with abdominal aortic aneurysm (AAA) and after AAA endovascular repair (EVAR). This study investigates the effect of antiplatelet agents (APLs) on the prothrombotic diathesis in the post-EVAR period. Forty elective EVAR patients had thrombin-antithrombin complex, d-dimer, fibrinopeptide A, and high-sensitivity C-reactive protein measured before, at 24 hours, 1 month, and 6 months after EVAR. Patients receiving APLs postoperatively were compared with those not receiving APLs. All biomarkers were above the normal limits preoperatively and increased significantly 24 hours postoperatively followed by a drop at 1 and 6 months. No statistically significant changes were noted among patients receiving APLs in comparison with those not receiving APLs. The preoperative and postoperative prothrombotic diathesis of AAA following EVAR was confirmed in line with other reports. There was however no significant alteration of the examined biomarkers in patients receiving APLs.

Endovascular management of peripheral arterial trauma in patients presenting in hemorrhagic shock.

AIM: This study investigated patients who sustained peripheral arterial trauma, presented with clinical signs of shock, and underwent urgent endovascular repair (endo-R). METHODS: Eighteen patients (11 men) aged 62.8 ± 17.5 y (range: 24-78 years) with severe peripheral arterial injuries or spontaneous ruptures who presented with clinical signs of shock were treated on an emergency basis at two institutions from August 2003 to August 2009. The injury mechanism and clinical presentation were assessed in all patients. The time interval from the initial event to the procedure, the time interval from hemodynamic instability to endo-R (HI-to-endo-RTI), the artery involved in the approach to the injured vessel, the method of endo-R, and the endo-R duration were recorded. Stent grafting and/or embolization of the injured vessel were performed. The outcome was assessed mainly by clinical examination and duplex scanning. The duration of follow-up ranged from 6 d to 60 mo (27.4 ± 17.8 mo, mean ± SD). RESULTS: Mechanisms of injury included 13 iatrogenic (9 catheter-related) injuries, 2 spontaneous hemorrhages, and 1 case each of gunshot wound, fall injury, and car accident. Traumatic lesions were in the external carotid (N.=1), vertebral (N.=1), subclavian (N.=3), common iliac (N.=1), external iliac (N.=5), internal iliac (N.=3), profunda femoral (N.=1), superficial femoral (N.=2), and popliteal (N.=1) arteries. Stent grafts and embolotherapy were successfully deployed in 12 and 4 patients, respectively, with complete exclusion of the bleeding site. One patient received both treatments and another patient received balloon occlusion therapy. Technical success with no procedural complications occurred in all cases. The mean event-to-procedure time interval, HI-to-endo-RTI, and operative time were 147 min, 42.2 ± 48.2 min (range: 3-180 min), and 40.0 ± 29.6 min (range: 5-110 min), respectively. Thirteen patients had an uneventful postoperative course while three patients died (mortality rate: 17%). One patient had below-knee amputation and another one suffered hemiparesis (morbidity rate: 11%). The durations of the hospital and intensive-care-unit stays were 16.6 ± 19.5 d (range: 2-62 d) and 6.4 ± 14.6 d (range: 0-60 d), respectively. The follow-up duration was 27.4 ± 17.8 mo (range: 0.2-60 mo). Freedom from early or late endo-R major events occurred in 71.4% and 65.6% of cases at 6 mo and 12 mo, respectively, and the rate of primary patency of endografts was 91.7% and 81.8%. CONCLUSION: Endo-R of traumatic non-aortic arterial injuries or spontaneous ruptures might be considered as a treatment option-in preference to open repair-even in emergency settings such as in shock patients. However, the safety of endovascular treatment in unstable trauma patients must be proved after comparison with open surgical treatment.

Publications in vascular journals: contribution by country.

The geographical origin of all published papers in four major vascular journals as well as the "vascular papers" in two high impact "general" surgical journals during a four year period (2003-2006) were examined by search of their electronic editions. As an index of high quality papers, the randomized controlled trials (RCT's) by country were also examined. A total of 3422 papers were searched in the four vascular journals (115 RCT's) while 144 "vascular" papers (19 RCT's) were located in the two "general" surgical journals. It was not surprising that USA and western European countries were having the largest contribution to the vascular literature.